What do women want? Migrant and refugee women’s preferences for the delivery of sexual and reproductive healthcare and information

ABSTRACT

Objective

Migrant and refugee women experience inequities in sexual and reproductive health (SRH) care, reflected in the low uptake of SRH services. It is essential for healthcare providers and educators to be aware of women’s preferences for SRH information and service delivery, to provide culturally responsive care. Identifying migrant and refugee women’s preferences for SRH information and service delivery is the objective of this study.

Design

This study investigated this issue, in communities of migrant and refugee women living in Australia and Canada. Eighty-four individual interviews and 16 focus groups comprising 85 participants were conducted (total n = 169), with migrant and refugee women aged 18 years and over from Afghanistan, India (Punjab), Iraq, Somalia, South Sudan, Sri-Lanka (Tamil), Sudan and various South American (Latina) backgrounds. Nine individual interviews were also undertaken with community interviewers, who were migrant or refugee women themselves.

Results

Thematic analyses identified that migrant and refugee women are enthusiastic to learn about SRH across the lifespan, using a variety of modalities including group education delivered by community leaders; online and written material; and information provided by general practitioners. Participants emphasised the need for empathetic SRH care, which encompassed longer times for consultations, being seen as experts of their own bodies, privacy and healthcare provided by women practitioners. Greater engagement with migrant and refugee men was positioned as an additional solution to addressing SRH concerns of women.

Conclusion

Insights from this study can help facilitate the co-design and evaluation of acceptable and sustainable programs to address inequities in SRH experienced by migrant and refugee women.

KEYWORDS:

• Sexual and reproductive health
• migrant and refugee women
• healthcare services
• sexual health education
• qualitative

Introduction

In 2016, 65.6 million people globally were forced to leave their homes, this included internally displaced people and over 22.5 million refugees – the highest number since World War ІІ (UNHCR 2016). High-income countries such as Australia and Canada, the context of this study, host some of the largest and most diverse populations of culturally and linguistically diverse (CALD) migrant and refugee persons globally. The term CALD is used in Australia to describe people who have a cultural heritage different from the dominant Anglo Australian culture (Department of Health 2016), replacing the previously used term of people from a ‘non-English-speaking background’. As this term is not used in Canada, where many of our participants reside, we are describing our participants as ‘migrant and refugee women’. The cultural diversity of the Australian population is exemplified in the fact that 29.7% of the population were born overseas (7.5 million people), of which 21% speak a language other than English at home (Australian Bureau of Statistics 2020). Similarly, in 2016 migrants made up over one-fifth of the total population of Canada, the large majority coming from non-English-speaking low-income countries (Statistics Canada 2017a). On arrival to Australia and Canada, most migrants are between the ages of 20–44 years, with more than 50% being women (Statistics Canada 2017b; Australian Bureau of Statistics 2020). The ongoing refugee crisis, and the continued influx of migrant and refugee women to high-income countries, means that addressing the sexual and reproductive health (SRH) needs of these populations is a priority issue.

In Australia, Medicare is the scheme that gives Australian permanent residents and citizens access to healthcare. Medicare covers all of the cost of public hospital services and some or all of the costs of other health services, including general practitioners, medical specialists and subsidised pharmaceuticals. While most resettled migrants and refugees have access to Medicare coverage, this is not the same for all people seeking asylum. Those who are ineligible for Medicare, may be eligible for a fee waiver to access the public health system in emergencies, but experience difficulties in accessing primary care, often relying on charitable organisations, including free sexual health clinics. They may also be unable to access certain Commonwealth-funded health services, such as free interpreting services during consultations with doctors. Similar to Australia, Canada follows a free or subsidised public health insurance scheme for citizens and permanent residents. However, unlike Australia, all refugees and refugee claimants can access the same basic coverage as those eligible for public health insurance through the Interim Federal Health Program (Canadian Government 2021). This temporary cover includes free access to hospital services, medical doctors and other healthcare professionals, until eligible for the public health insurance scheme.

Migrant and refugee women are often transitioning from contexts where women’s SRH rights may not be upheld, and where sociocultural beliefs and practices surrounding SRH may differ vastly from that of their countries of resettlement (Ussher et al. 2017; Hawkey, Ussher, and Perz 2019). In many cases, refugee women are migrating from countries where medical resources are scarce or non-existent due to war, or where a system for women’s health does not exist (Fink et al. 2014). Refugee women often report having suffered traumatic experiences, including being victims of physical violence, sexual abuse, rape and extortion, prior to migration, and during the migration process (Byrskog et al. 2014). A meta-analysis across 14 countries estimated more than 21% of refugee and internally displaced women experienced sexual violence; a number which is likely to be underestimated due to underreporting (Vu et al. 2014). These findings suggest that refugee women are likely to have complex SRH needs following migration.

While migrant women arriving on family or skilled visas are less likely to have experienced war and trauma, they still encounter significant SRH inequalities compared to Australian and Canadian-born women (Khanlou et al. 2017). For example, both migrant and refugee women face a range of material barriers to accessing SRH services including; language difficulties, challenges in navigating complex healthcare systems, transport difficulties and the cost of services (Mengesha, Dune, and Perz 2016; Rade et al. 2018). Migrant and refugee communities are also less likely to know about or access services for SRH (Åkerman et al. 2017) and report migrating from contexts where information about SRH is not readily available (Svensson, Carlzén, and Agardh 2017). Poor access to SRH services is problematic as it provides an opportunity for women to obtain adequate information for informed decision-making, associated with health-promoting and disease prevention sexual and reproductive behaviours (Benson et al. 2010). It is also associated with positive mental health outcomes and greater quality of life (WHO 2009).

Past research has highlighted that both migrant and refugee women are less likely to participate in preventative health behaviours, such as cervical screening, compared to native-born women (Aminisani, Armstrong, and Canfell 2012). They also disclose difficulties in accessing appropriate contraception information or contraception methods (Åkerman et al. 2017). A lack of access to appropriate sexual health services and resources place women at increased risk of cervical cancer (Alloteyet al.2004) or unintended pregnancy (Rademakers, Mouthaan, and de Neef 2005), which has implications for women’s health and psychosocial wellbeing (Kirkman et al. 2011). Past research has also highlighted that migrant and refugee women may have limited knowledge of sexually transmitted infections (STI’s) (Metusela et al. 2017), which may in part explain higher rates and later diagnosis of HIV within these communities. For example, in Australia, people born in Southeast Asia, the Americas and Sub-Saharan Africa have the highest rates of HIV diagnoses; heterosexual migrant women from East Asia and Sub-Saharan Africa are also significantly more likely to receive a late HIV diagnosis compared to the Australian born population (Kirby Institute 2018).

Perceived risk of disease, associated with poor health literacy across sexual and reproductive topics is likely to contribute to low uptake of health services and testing (Åkerman et al. 2017; Metusela et al. 2017). In many migrant and refugee communities, talk of SRH is considered shameful and taboo, restricting women’s access to information and services (Ussher et al. 2017). Studies have also suggested that when migrant and refugee women do access services they may experience stigma and discrimination (Agu et al. 2016), receive culturally insensitive care, or have mismatched expectations of care (Pavlish, Noor, and Brandt 2010). In combination, this is likely to impact on their willingness to connect with services in the future. This underscores the need for healthcare providers and educators to be aware of specific cultural beliefs, practices and preferences in relation to women’s SRH to provide culturally competent care both within and outside of a clinical context (Mengesha et al. 2018).

There is an abundance of research that highlights the individual, sociocultural and structural barriers to migrant and refugee women’s SRH (Mengesha, Dune, and Perz 2016). However, there is limited understanding of the preferences of migrant and refugee women in relation to SRH information and service delivery, and how SRH service uptake can be facilitated, from the perspectives of women within these communities (Rade et al. 2018). This is despite the fact that SRH has been identified as a priority area for information and support among migrant and refugee women internationally, including those living in Australia (Lee, Sulaiman-Hill, and Thompson 2013) and Canada (Chowdhury et al. 2020). Due to limited English literacy, migrant and refugee women are frequently excluded from participating in population-based studies aimed to examine gaps in women’s health information and needs (Jean Hailes 2020), meaning they have fewer avenues to voice their needs and preferences. Research that does exist surrounding migrant and refugee women’s SRH delivery preferences is about pregnancy and birth (Gagnon and Redden 2016), focuses on healthcare professionals perspectives (Mengesha, Dune, and Perz 2016) or asks migrant and refugee women about preferences for ‘health’ information in general (Lee, Sulaiman-Hill, and Thompson 2013). The following article addresses this gap in the research literature by exploring migrant and refugee women’s preferences for the delivery of SRH information and care.

Materials and methods

Design

This qualitative study was conducted in Sydney, Australia and Vancouver, Canada, part of a larger program of research considering migrant and refugee women’s constructions and experiences of SRH across the life span (Ussher et al. 2017). Eighty-four individual semi-structured interviews (61 in Sydney and 23 in Vancouver) and 16 focus groups comprised of a total of 85 participants (25 participants in Sydney and 60 in Vancouver) were conducted with migrant and refugee women, between July 2014 and November 2015. Focus groups and interviews were selected by researchers for data triangulation to strengthen our understanding of women’s experiences across different research methods. Specifically, focus groups were adopted to gain collective cultural constructions and social knowledge through participant interaction, and interviews were utilised to explore individual experience in depth (Carter et al. 2014). We also conducted nine semi-structured interviews with the community members who undertook the individual interviews with non-English-speaking migrant and refugee women. This approach was adopted to give voice to a range of stakeholder perspectives and because the majority of community interviewers had experience working as bilingual support workers, meaning they have unique insights into the day-to-day issues faced by women within their communities. Australia and Canada were chosen as the geographical site because both are English-speaking countries that resettle large numbers of non-English-speaking refugees, and host similar migrant and refugee communities.

Participants

Participants were between 18 and 70 years old and had resettled to Australia or Canada in the last 10 years, from Afghanistan, India (Punjab), Iraq, Somalia, South Sudan, Sri Lanka (Tamil), Sudan and various South American (Latina) backgrounds. Most participants had migrated to Australia or Canada on a Humanitarian Visa, with a mean time since the migration of 7 years. All but one Latina woman, who disclosed being in a same sex relationship, identified as heterosexual. Women practised a range of religions, with most identifying as Muslim or Christian. Table 1 provides further detail surrounding participant demographics. Community interviewers were women from the same cultural background as the women they interviewed (n = 7), or who spoke the same language as the women they interviewed (n = 2). All community interviewers were either migrant or refugee women themselves. Two community interviewers (one South Sudanese and one Afghan) chose not to participate in an interview due to time constraints.

Table 1. Sample sociodemographic characteristics.

Variable/Group	Afghani	Iraqi	Latina	Somali	South Sudanese	Sudanese	Tamil
	(n = 35)	(n = 27)	(n = 17)	(n = 38)	(n = 11)	(n = 20)	(n = 12)
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
Age	31.4 (9.1)	38.7 (12.5)	37.1 (5.6)	31.9 (10.4)	36.6 (6.2)	38.7 (7.5)	36.8 (7.3)
Years since migration	5.1 (4.1)	4.3 (2.1)	8.3 (4.9)	5.4 (3.1)	10.8 (2.1)	8.9 (3.4)	5.1 (2.5)
Number of children	3.3 (1.3)	2.7 (1.2)	1.5 (0.7)	3.7 (2.0)	4.5 (2.2)	2.9 (1.1)	2.1 (0.5)
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Have children
Yes/pregnant	20 (57.1)	20 (74.1)	11 (73.3)	23 (60.5)	11 (100.0)	19 (95.0)	11 (91.7)
No	15 (42.9)	7 (25.9)	6 (26.7)	15 (39.5)	–	1 (5.0)	1 (8.3)
Religion
Islamic	35 (100.0)	23 (85.2)	–	38 (100.0)	–	16 (80.0)	–
Christian	–	3 (11.1)	10 (58.8)	–	11 (100.0)	4 (20.0)	5 (41.7)
Buddhist	–	–	1 (5.9)	–	–	–	–
Hindu	–	–	–	–	–	–	7 (58.3)
Non–practising	–	1 (3.7)	6 (35.3)	–	–	–	–
Education
Primary	7 (20.0)	6 (22.2)	–	8 (21.1)	3 (27.3)	4 (20.0)	–
Secondary	15 (42.9)	3 (11.1)	2 (11.8)	3 (7.9)	2 (18.2)	5 (25.0)	7 (58.3)
Tertiary	6 (17.1)	18 (66.7)	10 (58.8)	3 (7.9)	2 (18.2)	10 (50.0)	5 (41.7)
Nil	2 (5.7)	–	–	1 (2.6)	2 (18.2)	1 (5.0)	–
Other	1 (2.9)	–	–	2 (5.3)	2 (18.2)	–	–
No response	4 (11.4)	–	5 (29.4)	21 (55.3)	–	–	–
Relationship status
Married/de-facto	17 (48.6)	14 (51.9)	13 (76.5)	13 (34.2)	6 (54.5)	13 (65.0)	12 (100.0)
Single	12 (34.3)	7 (25.9)	2 (11.8)	14 (36.8)	1 (9.1)	1 (5.0)	–
Divorced/separated	2 (5.7)	5 (18.5)	2 (11.8)	8 (21.1)	4 (36.4)	6 (30.0)	–
Widowed	4 (11.4)	1 (3.7)	–	3 (7.9)	–	–	–

Procedure

This research study was approved by Western Sydney University and Simon Fraser University Ethics Committees, as well as the ethics committee of one of our project partners – Family Planning New South Wales. Community stakeholders, who provide support and SRH care to migrant and refugee women, provided feedback on the research aims, methods and offered advice on appropriate research approaches with culturally diverse women. The research team trained bilingual community interviewers (n = 11) within each of the language or cultural groups to carry out interviews and focus groups; this included how to conduct interviews and focus groups, and interview data transcription and translation. Community interviewers spoke to 124 women in total, with a woman member of the research team conducting the remainder of interviews and focus groups with women who had conversational English (AH), or who wanted to be interviewed by a non-community member (n = 45).

We recruited for women who were over 18 years old and who had migrated to Australia or Canada in the past 10 years. Recruitment occurred utilising a number of strategies, including community support workers, community interviewers, flyers, community groups who meet regularly, and snowball sampling. Recruitment within cultural groups continued until few new concepts were occurring within women’s accounts. Prior to participation, women received information about the purpose of the research and what the study involved; all women gave informed consent to participate. Interviews and focus groups were undertaken at a location chosen by participants, including the participant’s home, community libraries, or migrant resource centres. Focus groups were homogeneous, consisting of women from the same cultural group, with separate groups for married and single women where possible. With permission from participants, interviews and focus groups were digitally audio-recorded, and lasted on average 90 min, with questions focusing on experiences of SRH, and preferences for information and services, the focus of this article. At the end of the data collection period, all community interviewers were invited to participate in an interview about their experiences of being involved in the study and ways they believed that SRH information and care should be provided to their communities or the communities they worked with.

Analysis

Interviews and focus groups conducted in the first language of participants were transcribed and translated into English by the community interviewers. Interviews and focus groups conducted in English were professionally transcribed verbatim and then integrity-checked by listening to the audio recording and reading the written text to ensure accuracy. All participant names were replaced by pseudonyms.

Our epistemological framework was critical realism, a framework that affirms both the materiality of an experience, but conceptualises this materiality as being mediated by culture, language and politics (Bhaskar 2011). Data was analysed using thematic analysis as described by Braun and Clarke (2006). To begin, a random subset of interview and focus group transcripts was read by two members of the research team. This allowed for the comparison of data across the two data types. Conceptually, we found no difference in the data. However, focus group data largely focused on general cultural beliefs and practices, while women in the interviews felt more comfortable sharing their own personal SRH experiences in greater depth. Transcripts were then re-read line-by-line in close detail, with notes added to capture relevant concepts or ‘codes’ coming from the data. Through a process of discussion and decision-making with the research team, we then defined first-order codes. After initial coding of approximately 12 transcripts, we then grouped first-order concepts where commonalities occurred, making a smaller number of more distinct categories. We then added concise overarching or higher-order codes, such as ‘preferences for information delivery’ and ‘current health practices’, under which first-order codes sat. This process lead to the development of our coding framework, which was applied to the remaining transcripts, converging both interview and focus group data. Once coding of all data was complete, each of the coded sections was summarised. The summary was an overview of the key points coming out of each code. We made reference to which participants said these accounts to refer back later during our write-up. Through the process of coding, re-reading the coded data, collating and summarising the data five main themes were identified in relation to women’s SRH information and care delivery. These are discussed in turn below.

Throughout our analysis, we engaged in a process of reflexivity, involving self-awareness of the intersubjective dynamics between the researcher and the researched, and critical reflection on how our social and cultural backgrounds, assumptions and positioning impacted upon the research process (Finlay and Gough 2003). The research team consisted of women of colour and white women; women who had migrated and those born in Australia and Canada; academic researchers, clinicians and those working with migrant women in the community. Our different experiences were reflected upon in the design of the research, and the analysis and interpretation of data, prioritising the voices of our community partners and our community interviewers. Our preliminary findings were also translated into a community forum with 62 attendees providing the opportunity for feedback on data analysis and interpretation, prior to broader dissemination.

Results

Our analysis found five central themes. The first two themes centre around SRH information and delivery preferences ‘Information on SRH across the lifespan’ and ‘Multiple modalities: Providing women with a variety of avenues to access information and support’. The third theme ‘A need for women-centred care: Empathy, time and feeling listened to’ speaks to women’s preferences for healthcare service delivery in the context of SRH. Theme four, ‘The need for embedded programs and community ownership’ describes the necessity for community involvement in the design and delivery of any SRH intervention. The final theme, ‘The need for greater engagement from men’ explores women’s preferences for men’s involvement and engagement with SRH information and care.

‘Understanding our cycles and our bodies’: Information on sexual and reproductive health across the lifespan

Across cultural groups, women described the value and importance of having access to SRH information, particularly since migrating from contexts where SRH was not discussed and information was difficult to access. As Rihana (Somali, community interviewer) shared, ‘for a woman who is educated, the blinds are open, you see things from every corner’. Women shared that they would appreciate more information about SRH topics across the lifespan. This started with menstruation, with participants describing they would like to know about, ‘different types of [menstrual] pads that we use … are they kind of like suitable enough’ (Setara, 23, Afghan). Many participants reported having received little or no menstrual education themselves, and that they wanted ‘totally [the] opposite with my daughter’ (Afghan, Focus Group). However, women disclosed needing support in providing meaningful menstrual education for their daughters, such as when to broach the topic and ‘how to talk to them’ (Nafisa, 36, Sudanese). For older women, menopause was most frequently mentioned as a topic they knew little about and wanted information about, specifically, ‘how your body changes, and what you get physically … I don’t know what happens in the body’ (Aameeka, 40, Tamil).

Across cultural groups both community members and the community interviewers recognised that sexual health is ‘not just an illness’ but an ‘physical … emotional … psychological and social health concern’ (Hirah, Iraqi, community interviewer). In this vein, women wanted further education about sexual intimacy – including sexual pain and pleasure, sexual rights and libido. This in part was because sex was positioned as a ‘taboo’ topic in all of the communities interviewed and that as a consequence ‘people don’t talk about it … it’s sometimes hard to find that information available’ (Catalina, 45, Latina). To facilitate the ‘normalisation’ of sex and sexual pleasure Hirah (Iraqi, community interviewer) shared that women in her community would benefit from knowing ‘more about sex’ including ‘more about intercourse, more about choice, more about comfort and discomfort of their body, what’s allowed, what’s not allowed, more about pleasing yourself and not feeling guilty, because overseas the education, everything is a no, no, no, no, no’. Naeem (Somali, community interviewer) said there is a need to ‘illustrate about women’s rights and feelings, how they can enjoy sex. It’s not a pain, it’s a pleasure. It’s never meant to be a pain.’

A number of women said that they would particularly value ‘information about sexual desire and libido’ (Mariana, 38, Latina), which can change over the life course. As a Sudanese focus group participant said ‘after 40, there's a lot changes happening, especially with the husband, the sexual relationship. So I need to know more information about that.’ Similarly, Minoo (32, Afghan) described she would find sexuality education ‘extremely helpful’ because, ‘women will be educated and can cope with their sexual life much better … it is very hard for women, men enjoy most of the time because they do it when they feel like it’. As a part of maintaining a healthy sex life, Naeem (Somali, community interviewer) described the importance of taking a holistic approach, saying ‘It's about wellbeing … it's about safety … it’s good to address it together, when they're stressed, when they're not happy and there's a marriage problem … [it] builds up and it gets … not a working relationship’.

Other participants spoke more generally about their sexual health concerns and need for information to address ‘worries about the sexual infections’ (Sudanese, Focus Group) which they ‘get scared’ about (Setara, 23, Afghani). Specifically, women want information on particular infections such as chlamydia and ‘how to protect myself’ (Sudanese, Focus Group), and ‘about prevention of social diseases and STDs’ (Isabella, 46, Latina). Other participants said that they would like ‘more information about prevention of cancer … vaginal cancer or uterus cancer, breast cancer’ (Ariana, 40, Latina), in addition to ‘knowing what they’re looking for … knowledge about the diseases that I might be in risk of’ (Akeck, 31, South Sudanese). A number of women reported that women in their communities needed information on ‘[the] usage of contraceptives’ (Setara, 23, Afghani). For example, Akoi (40 South Sudanese) said ‘I see women having babies, they are having 10, 11, they are going and going … they have health issues … so this is a real education that women need to know’. Given ‘mothers relay this information onto their kids’ (Reba, Sudanese, Community interviewer) women also wanted to learn how to educate their children about sexual health. As Kamelah (36, Sudanese) explained, ‘we didn’t learn, we can’t teach our children’.

Multiple modalities: providing women with a variety of avenues to access information and support

Participants expressed a range of preferences for the modality of SRH information provision, including face-to-face within a group, during a GP discussion, or through internet or written modalities. The majority of women reported that they would like to receive SRH information in a group discussion format. For example, ‘we need a group like this one because we can talk and can ask questions. So there's more communication’ (Sudanese, Focus Group); ‘I think the best would be for all women to come together and talk about these issues together, like a big meeting’ (Shiwa, 50, Afghani). Group discussion was reported to facilitate women sharing their own experiences and learning from one another, as Nadima (34, Sudanese) said, ‘I got very useful information … I found other women have same situation like me, they telling their stories [it] was so good and useful because you learn from other people’s experience’. Community interviewers shared that a group format may help to normalise difficult conversations, saying ‘have a women’s group, talk more about sex and understand it is a part of life’ (Naeem, Somali, community interviewer) and ‘they get to meet other women and then share, step by step, it will lessen, the hostility around that topic’ (Rihana, Somali, community interviewer).

In contrast, several women reported that they preferred seeking information from healthcare professionals, particularly their GP, due to a reluctance to discuss SRH in front of other women. As Azita (37, Afghani) told us, ‘In my community because I am an Afghan, and I am a woman, we can’t talk in our community in a group, one-on-one is better’ (Azita, 37, Afghani). Others focused on ‘personalised’ information, with Manjit (33, Punjabi) saying, ‘one-on-one chat is probably more comfortable for people because it’s more personalised’. Homa (40, Afghani) telling us that seeking individual care from a GP meant she ‘could really get to the heart of my own problems’.

Some participants had a preference for written or visual information, obtained through the internet or through health education brochures. The utilisation of the internet for information was said to be a way to avoid shame associated with talking about SRH: ‘I don’t think you would want to ask people that [sexual health] … with the internet, you can still maintain your privacy’ (Punjabi, Focus Group). The internet was positioned as being very ‘convenient’, ‘accessible’ and ‘more comfortable’ compared to other methods, such as group sessions or GP visits, with social media being preferred outlets, particularly among younger participants. For example, Manno (19, Somali) said, ‘the best method that I would prefer is Facebook … everybody uses Facebook and YouTube so that this generation will know the information’. Several participants did acknowledge that the ‘internet would be hard, because I never used it’ (Azita, 37, Afghani) and ‘can be tricky, because there is so much information … and you never know about the quality of the source of the information, how reliable it is’ (Sofia, 40 Latina), suggesting some reservation about this modality of information provision.

Ease of access, and greater legitimacy in the status of the information, was associated with health education brochures obtained though GPs or clinics. For example, participants told us ‘a good way of disseminating that information is probably having the leaflets hanging around which people can just pick up and then read in their own time’ (Punjabi, Focus Group), and ‘rather than talking, if they can read … they can get the information comfortably’ (Aameeka, 40, Tamil). Women described such information could be a ‘booklet’ or, ‘brochure’ displayed in migrant resource centres or doctor’s clinics. For instance, one women said, ‘I also think that walk-in clinics are good places … it would be good to have it really in front of your eyes’ (Latina, Focus Group). However, participants stressed the importance of having written resources in their native languages, as described by Azita (37, Afghani):

Me and most women that are coming from Afghanistan can't speak English and aren't aware where to go for this kind of topics … in future I would like to see little information books in doctor clinics, so we could read and could speak about it.

A need for women-centred care: empathy, time and feeling listened too

Many women described currently receiving good quality SRH, especially in comparison to their home countries. However, a minority of participants articulated instances in which they perceived the care they received to be unsatisfactory. For example, some women discussed feeling rushed in consultations, stating that ‘the doctor just saw us for two minutes’ (Latina, Focus Group) and that the doctor only sees patients for ‘five minutes’, which gives the impression they are ‘very cold and impersonal … they do not care much’ (Sofia, 40, Latina) or that ‘GPs are not very good starting points’ (Geet, 30, Punjabi). Other participants described feeling dismissed when trying to address SRH concerns, leaving consultations without a ‘tangible’ outcomes, being misdiagnosed or prescribed unsuccessful treatments. As Anu (35, Punjabi) described

I have gone to the doctor about sex because I do sometimes feel that my libido is quite low … I was very disappointed, nothing quite came out of that appointment … they just don’t take it seriously … I wasn’t really given a very, nothing tangible, nothing I could work on … I mean, she decided she should give me a depression test … it was strange to be honest.

Negative experiences of SRH care were worrying for some community interviewers, because they made women feel ‘like I’m not a human being’ and was described as being a core reason why ‘some women go [to the doctor] and others don’t’ (Hirah, Iraqi, community interviewer, Sydney).

All participants identified the need to create an environment of trust and comfort, where procedures are ‘done a bit slower’ and practitioners are ‘tender’ and ‘understanding’ with women from migrant and refugee backgrounds. This was because women were coming from contexts where discussion of sexual health and sexual health procedures were highly unfamiliar, as Andrea (26, Tamil) said, ‘we spend our lives, nearly 20 years back home, it’s a bit hard to change suddenly.’ For many women, this resulted in fear, uncertainty and embarrassment about discussing sexual health, with women telling us, ‘It’s kind of shameful to go to the doctor and say that I have my period, but it’s reduced … I’m shy, I don’t talk about it’ (Hawa, 30, South Sudanese) and that ‘[the] pap smear was so scary for me, the first time I had it done was here in Australia and I was really shaking and frightened … I did not even know what would be happening to me’ (Sharifa, 43, Iraq). To address embarrassment and fear, participants highlighted the importance of empathetic communication and clinicians taking their time with intimate procedures. As Hirah (Iraqi, community interviewer, Sydney) told us, ‘you need doctors to say hey, okay I am going to put my hand in, nothing’s going to hurt, don’t be afraid, don’t worry’. Creating a safe space for women to ‘relax and talk about your women’s health issues’ included confidentiality and privacy, without ‘someone knocking at the door every minute … there is no privacy. It’s not an encouraging environment’ (Naeem, Somali, community interviewer).

A minority of participants prioritised clinician professionalism and experience, regardless of clinician gender. However, the majority of women preferred to receive SRH information and care from women healthcare providers. Participants told us, ‘Every time I ask for a medical advice … I tell them I want female doctor, even in the menstrual period, I can’t talk about to a male doctor’ (Iraqi, Focus Group). For some participants, this was described as a ‘cultural’ thing and was particularly important when receiving examinations such as cervical screening; ‘I’ve had all my pap smears done by female doctors. That’s just, I think, my own anxiety about having another man touch me in some way’ (Punjabi, Focus Group). In this vein, one suggestion to provide safe and welcoming women-centred services was through ‘targeted women’s health centres’ or a ‘woman’s health clinic’ (Naeem, Somali, community interviewer).

‘Change needs to come from within’: the need for embedded programs and community ownership

The majority of women we interviewed described themselves as the primary caretaker within the family, which had implications for the prioritisation of their SRH care. Participants explained that ‘in most cases, they [women] are taking care of a lot of people around them, but not themselves’ (Nafisa, 36, Sudanese) and that, ‘we don’t have time, we just rush’ (Kamila, 34, South Sudanese). The prioritisation of family needs was often exacerbated following migration, with women describing competing demands during their early settlement period. For example, Nasira (52, Iraqi) described:

When they [women] come to Australia, they are thinking of how to settle, how to find a house and how to engage their children in the schools, how to do all these things and they don’t have time for themselves … they ignore themselves.

One solution suggested by participants to addressing this issue was to embed SRH services within existing community activities or services. This included school functions, early childhood centres, antenatal clinics, community festivals, religious institutions and English classes. Participants shared, ‘Somali women, when they come here, they go to ESL [English as a Second Language] classes … it [SRH education] could be received through that … because it is incorporated into their life … I think it will help’ (Rihana, Somali, community interviewer) and that, ‘In my culture, people are really religious. I think the best thing would be … having a connection between our community groups and the mosque’ (Setara, 23, Afghani).

Given the sensitivity of SRH topics, participants also disclosed the importance of trust, specifically that education delivery ‘needs to be through a trusted source’ (Hanan, Iraqi, community interviewer). Utilising members of their own communities to deliver education sessions, such as religious clergy or bilingual community workers, was described as an important and a trustable source of information. For instance, women told us, ‘get the Afghans involved … an Afghan trusts an Afghan … they probably trust me fifty percent more than an Australian’ (Nadera, Afghan, community interview) and that ‘through bilingual workers, because it’s not easy for these women to talk, even these bilingual workers have to be trustable’ (Sahar, Sudanese, community interviewer). One community interviewer told us, ‘I think it has to be within the community … change needs to come from within’, because ‘a Westerner trying to do something … it’s just very complicated, especially from someone who doesn’t share their culture, it would be incredibly difficult’ (Reba, Sudanese community interviewer). Naeem (Somali, community interviewer) gave an example of this drawing on her experience as a community support worker, sharing; ‘Women were asking me, ‘why aren’t you having any more babies? What have you done?’ I told them I have an IUD … even giving them my scenario gave them confidence’.

‘Teach men before you teach us’: the need for greater engagement from men

While all participants acknowledged the importance of continued SRH education for migrant and refugee women, the majority problematised the lack of men’s involvement with SRH. An Iraqi focus group member said that men need ‘a course on how to treat a woman … they need some advice’ and Nadiya (70, Iraqi) told us ‘even the man, must know how to treat their women, how to take care of them about sex’. While women positioned themselves as being more ‘flexible’ and ‘open to other cultures’, men were seen as ‘less accepting’ and ‘harder to get through to’ (Naeem, Somali, community interviewer). This resulted in men being described as less likely to attend community education sessions or take information on board: ‘women always come to the sessions and not men … we have to access the men as well’ (Sahar, Sudanese, community interviewer). Consequently, when ‘women go and get the information and try to pass that information to their husbands, but husbands never agree or accept those information’ (Husna, 45, Sudanese). For some women, this resulted in feeling ‘frustrated’ because ‘it doesn’t matter how much they educate themselves and try and do the research how to make sex pleasurable, they can’t train him … it’s like going through a storm’ (Naeema, Somali, community interviewer). A minority of women also described that men played a gate keeping role in their access to SRH care. As Kamila (34, South Sudanese) told us

I have to tell him, I went to the doctor and the doctor says this and this, if you have a prescription and you don’t have enough money, you can give him the prescription to get you the medicine, because you don’t have enough money.

These accounts exemplify that while many women are eager to learn about their SRH and access services, without men’s involvement women may remain disempowered and potentially denied the SRH services they need.

Discussion

There is an increasing body of literature that identifies barriers to migrant and refugee women’s SRH. However, little attention has been paid to how women from migrant and refugee backgrounds would like to receive SRH information and care. This qualitative study addresses this gap in the research literature.

The findings of this study demonstrate that migrant and refugee women, across cultural groups, would like increased access to SRH information. These reported gaps in knowledge may be a reflection of limited access to SRH care or healthcare system failures pre-migration (Svensson, Carlzén, and Agardh 2017), combined with the taboo nature of SRH leading to shame and silencing of women’s sexual concerns (Ussher et al. 2017). In particular, participants discussed the need for increased information related to sexuality, including sexual pain and pleasure, libido, sexual rights and maintaining healthy intimate relationships. Addressing these topics is an important rights-based issue, as women are entitled to pain-free pleasurable sex (WHO 2006). Sexual health is also important in relation to women’s sexual subjectivity, as painful or unwanted sex is often associated with shame, distress, and feelings of inadequacy as a woman (Ayling and Ussher 2008). The request for more information on sexuality may also reflect the dominance of disease prevention within existing health promotion education frameworks, which almost exclusively focus on negative sexual health outcomes, such as HIV/ STI’s, cancer and pregnancy prevention (Ford et al. 2019). SRH is broader than ‘an absence of disease’ (WHO 2006), and thus health education, public health policy and programs for migrant and refugee women need to include discussion of healthy sexuality, accounting for the intertwined nature of relationships, pleasure, sexual health, sexual and reproductive rights and wellbeing (Landers and Kapadia 2020).

Participants described a preference for SRH information to be delivered across several different modalities, with preferences differing according to topics of discussion, age, literacy and competency using technology. This finding highlights the importance of offering SRH information to migrant and refugee women in a variety of ways. For many participants, shame in discussing SRH meant that they preferred one-on-one doctor’s consultations with women healthcare providers. This emphasises the need to work towards public health policy that ensures universal access to SRH services and education to empower women with choice and control in decision-making about their bodies (Hawkey et al. 2017). The opportunity to access written information on the internet or in brochure form was also seen favourably among some participants. The development of interactive tools (e.g. web-based tools and phone applications) for women to access evidence-based knowledge to increase SRH literacy and help-seeking behaviours, is a priority outlined in the Australian National Women’s Health Strategy 2020–2030 (Australian Government Department of Health 2018). Such approaches may facilitate ameliorating some systemic barriers in accessing SRH services such as time, cost and travel, by enabling women to access information at time and place that best suits them. While scoping studies suggest that interventions such as digital storytelling for young people (Botfield et al. 2017) and the use of mobile health (mHealth) (Bartlett et al. 2020) may be efficacious in promoting SRH, there is an absence of literature that speaks to development and evaluation of such interventions among migrant and refugee communities in Australia or Canada. Working with migrant and refugee women to co-design and evaluate the effectiveness of communicating information through multimedia should thus be a priority area for future research (Hughson et al. 2018).

Many women spoke of group education sessions as a preferred approach to receive SRH information. This reflects previous research where newly arrived migrant women disclosed that interactive talks would be a non-threatening environment to engage in sensitive topics such as family violence, provided they were embedded within broader health education sessions (Lee, Sulaiman-Hill, and Thompson 2013). Small-group peer education has also shown promise addressing sensitive topics such as HIV (Drummond et al. 2011) and could thus be extended to include other areas of SRH. Considerations could also be made for the delivery of group sessions online, particularly in the current global context of the COVID-19 pandemic where face-to-face gatherings may be difficult. This too is an area that needs further research to explore efficacy and acceptability.

Health providers play an essential role in creating a safe, judgement-free and confidential environment for women to share health concerns relating to SRH, as described by women in this study. When women felt rushed, as though their concerns were not taken seriously, or procedures were carried out insensitivity, they described disappointment and a reluctance to return. This is problematic, as migrant and refugee women may already face a multitude of barriers to accessing SRH services, including distrust in healthcare providers arising from their pre-arrival experiences (Mengesha, Dune, and Perz 2016), and are significantly less likely to engage in services compared to Australian born women (Mazza et al. 2012). This has implications for clinical practice. Healthcare professionals must consider additional complexities and contexts of migrant and refugee women’s lives, when tailoring the delivery of SRH services. For example, migrant and refugee women may have been victims of sexual trauma prior to migration (Byrskog et al. 2014), and due to exploitative structural factors and patriarchal gender norms are at increased risk of reproductive coercion and sexual violence upon resettlement (Tarzia, Douglas, and Sheeran 2021). Appropriately addressing these sensitive issues requires person-centred care; acknowledging religious variability, cultural heterogeneity and women’s unique migratory experiences and their impacts on SRH (Arousell and Carlbom 2016). To do this, healthcare professionals must have sufficient time in consultations to build trust with patients, and for deep listening to women’s concerns in a confidential and safe environment.

As migration to countries such as Australia and Canada continues to diversify our populations, there is a need for training and support for healthcare professionals who care for migrant and refugee communities. Previous research has highlighted that healthcare professionals may feel under-prepared to treat migrant and refugee women, requiring further education and training to strengthen their ability to support women’s SRH in a clinical context (Mengesha et al. 2018). Training could include addressing culturally specific issues – such as female genital cutting (Ogunsiji and Ussher 2021) and acute SRH issues faced by migrant and refugee women, as well as strategies for effective provider-patient communication (Jirovsky et al. 2018). To ensure clinicians have understanding of the complexities of migrant and refugee women’s SRH, education about SHR should also be introduced as an integral part of undergraduate medical school curriculum.

SRH promotion and education for migrant and refugee women needs to be culturally appropriate and spiritually significant. Thus, health-promoting activities benefit from being community designed and community-led (Newton et al. 2012), with involvement from reputable community leaders, such as religious clergy or bicultural workers, as highlighted by women in this study. To achieve this, it is important that moving forward health providers form partnerships with multicultural community organisations and communities themselves to build capacity and exchange information about the specific needs of communities (Hach 2012). Without such community buy-in, education and informational resources may be viewed as patronising or irrelevant to women and their wider communities. The prioritisation of women’s family and resettlement issues is concerning and reflects the need for education and SRH services to be easily available to women. This could include for example, running women’s health education sessions from schools or day cares, community events, and aligning education with English classes, where women are likely to be attending (Lee, Sulaiman-Hill, and Thompson 2013), as suggested by women in this study.

Participants in this research felt that greater involvement of men in education may increase partner support to access sexual health services, contraception and to enjoy healthy sexual lives. Currently, there is a dire lack of SRH research that explores migrant and refugee men’s constructions and experiences of SRH despite the role that men’s active participation has in the success of programs and the empowerment of women (Sternberg and Hubley 2004). This must be one focus of future research. Such programs could promote alternative constructions of masculinity and support men to understand the benefits to their wife and the family if women’s sexual and reproductive rights are recognised (Flood 2005). The most effective means of providing such education would likely be using peer educators, who are men from the same cultural background; this is because male educators can act as role models for men and because they may have ‘insiders’ knowledge (Flood 2005).

Strengths of the study include participants being interviewed in their first language enabling women who were not fluent in English to participate, as they were not constrained by language issues. The community interviewers were also able to explain terms such as menstruation, menopause, contraception and cervical screening in language that the participants understood. We spent a considerable amount of time building rapport and establishing a strong working relationship with community interviewers and the community, along with flexibility in the choice of the interviewer to ensure cultural safety throughout the research process. Limitations include the inability of researchers to back-check translated transcripts for accuracy and the fact that transcripts were not member checked. This process would be a helpful addition to future research studies with migrant and refugee women and would facilitate the validation of findings and accuracy of interpretation. Given the small number of women interviewed from each cultural group, experiences and constructions may not be representative of the communities as a whole. Similarly, given this research is specific to the context of Australia and Canada, our findings may not be generalisable to other Western countries that host migrant and refugee women.

Our findings demonstrate that migrant and refugee women are enthusiastic to learn about SRH across a range of topics, using a variety of modalities. This included programs embedded within existing community activities, with sexual health education delivered by community leaders; online and written material; and GP information delivery. When accessing healthcare services for SRH, women emphasised the need for empathetic care, privacy, longer times for consultations and healthcare that was provided by women practitioners. Participants articulated the role that men play in women’s SRH. They called for the greater engagement of men as a solution to addressing a variety of SRH concerns experienced by women. To conclude, our findings reiterate that a ‘one size fits all’ approach to the provision of SRH education and care is unlikely to meet the requirements of migrant and refugee women who report diverse needs and preferences for information and service delivery. Moving forward there is a need to co-design and evaluate a suite of approaches if the SRH inequities of migrant and refugee women are to be addressed in an accessible and culturally meaningful way.

Acknowledgments

This study was funded by an Australian Research Council Linkage Grant LP130100087, in conjunction with Family Planning New South Wales (FPNSW), The Community Migrant Resource Centre (CMRC) and Centre for the Study of Gender, Social Inequities and Mental Health, Simon Fraser University, Vancouver, Canada.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Australian Research Council Linkage Grant: [Grant Number LP130100087].